- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,469.14 / $1,836.42 / $10,602.30
| Facility | | $1,469.14 | $1,836.42 | $10,602.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.14 / $1,665.02 / $2,203.69
| Professional | | $1,469.14 | $1,665.02 | $2,203.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.74 / $1,751.75 / $9,207.08
| Facility | | $1,229.74 | $1,751.75 | $9,207.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,982.60 / $2,982.60 / $3,573.49
| Professional | | $2,982.60 | $2,982.60 | $3,573.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.14 / $1,469.14 / $2,081.28
| Professional | | $1,469.14 | $1,469.14 | $2,081.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $2,448.56 / $3,672.84
| Facility | | $2,448.56 | $2,448.56 | $3,672.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.00 / $1,028.40 / $3,836.55
| Professional | | $857.00 | $1,028.40 | $3,836.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.14 / $1,469.14 / $1,469.14
| Professional | | $1,469.14 | $1,469.14 | $1,469.14 |